Aneurisma de arteria iliaca: una causa de dolor abdominal agudo de alto riesgo

El dolor abdominal de alto riesgo es una condición común en los servicios de emergencia y está asociado a una alta morbilidad y mortalidad, si no se diagnostica y trata de manera rápida y precisa. Un hombre con síntomas de cólico nefrítico se presentó en emergencia con dolor abdominal intenso y deterioro clínico. Después de una tomografía, se encontró una imagen aneurismática en la arteria iliaca común primitiva izquierda. El paciente fue trasladado a sala de operaciones para una reparación quirúrgica, pero falleció. El dolor abdominal de alto riesgo requiere un abordaje diagnóstico integral y tratamiento individualizado para prevenir complicaciones graves. El aneurisma de la arteria iliaca complicado es una causa potencialmente grave de dolor abdominal en hombres fumadores de edad avanzada con antecedentes de hipertensión y aterosclerosis.

Life-Threatening abdominal pain is a common condition in emergency departments and it is associated with high morbidity and mortality, if not promptly and accurately diagnosed and treated. A man with symptoms of renal colic presented to the emergency room with severe abdominal pain and clinical deterioration. After a CT scan, an aneurysmatic image was found in the left primitive iliac artery. The patient was taken to an operating room for surgical repair but died. Life-Threatening abdominal pain requires a comprehensive diagnostic approach and individualized treatment to prevent serious complications. The complicated iliac artery aneurysm is a potentially serious cause of abdominal pain in elderly male smokers with a history of hypertension and atherosclerosis.

A novel balloon-assisted technique to secure visceral catheterization during a chimney endovascular repair of a ruptured abdominal aortic aneurysm in a centenarian patient / Uma nova técnica assistida por balão para assegurar a cateterização visceral durante o reparo endovascular, com a técnica de chaminé, de um aneurisma de aorta roto em um paciente centenário

Abstract A 100-year-old male patient was admitted with a ruptured abdominal aortic aneurysm due to type IA endoleak. Given the proximity of the ruptured site to the superior mesenteric artery (SMA) and renal arteries, a ChEVAR was indicated. Catheterization of the target visceral vessels was a challenging procedural step because of an intensely tortuous thoracic aorta. This hostile aortic anatomy also inhibited exchange for a super stiff guide-wire and selective cannulation with the diagnostic catheter was repeatedly lost when guidewire exchange was attempted. To overcome this issue, a 5 x 40 mm balloon catheter was placed 3cm into the target arteries. The balloon was then inflated below the nominal pressure limit enabling safe exchange for a super stiff guidewire and placement of three 90-cm long 7Fr guiding sheaths. The procedure was thus safely performed with deployment of an aortic extension and the bridging stents.

Resumo Um paciente de 100 anos foi diagnosticado com um aneurisma de aorta abdominal roto por um endoleak 1A. Pela proximidade do ponto de ruptura com a artéria mesentérica superior (AMS) e as artérias renais, um ChEVAR foi indicado. A cateterização das artérias-alvo foi um passo desafiador pela intensa tortuosidade da aorta torácica. Essa anatomia aórtica hostil também impediu a troca por um fio-guia extra-rígido, e a cateterização seletiva foi repetidamente perdida quando a troca de fio-guia foi tentada. Para superar essa dificuldade, um cateter balão 5mm x 40mm foi posicionado nas artérias-alvo. O balão foi, então, insuflado abaixo da pressão nominal, permitindo uma troca segura do fio-guia por um fio-guia extra-rígido e o posicionamento de três bainhas longas 7Frx 90cm. Assim, o procedimento foi executado de forma segura, com o implante de uma extensão aórtica e dos stents recobertos.

Endovascular treatment of ruptured lobulated anterior communicating artery aneurysms: A retrospective case series study of 24 patients / 国际脑血管病杂志

Objective:To investigate the efficacy and safety of endovascular treatment for ruptured lobulated anterior communicating artery aneurysm (ACoAA).Methods:Patients with ruptured lobulated ACoAA received endovascular treatment in Sanming First Hospital Affiliated to Fujian Medical University from June 2020 to June 2022 were retrospectively included. Their demographic, clinical and imaging characteristics, endovascular treatment methods and follow-up results were collected.Results:A total of 24 patients with ruptured lobulated ACoAA were included, including 9 males (37.5%) and 15 females (62.5%). Their age was 56.2±8.9 years old (range 39-74). The time from rupture to endovascular treatment was 10.9±12.5 h. The maximum diameter of the aneurysms was 5.1±1.0 mm and neck width was 3.0±0.7 mm. Nineteen patients (79.2%) were double-lobed and 5 (20.8%) were multilobed. Fisher's grade: grade 2 in 16 cases (66.7%), grade 3 in 6 cases (25%), and grade 4 in 2 cases (8.3%). Hunt-Hess grade: grade 0-2 in 5 cases (20.8%), grade 3-5 in 19 cases (79.2%). Glasgow Coma Scale score: 9-12 in 14 cases (58.3%), 13-15 in 10 cases (41.7%). Immediately postprocedural Raymond-Roy grade: grade 1 in 23 cases (95.8%), grade 2 in 1 case (4.2%). Raymond-Roy grade in imaging follow-up for 2 weeks to 3 months: grade 1 in 23 cases (95.8%), grade 2 in 1 case (4.2%). Follow-up for 2 to 12 months showed that 21 patients (87.5%) had good functional outcomes (modified Rankin Scale score ≤2), and there were no deaths.Conclusion:Endovascular treatment is a safe and effective treatment for ruptured lobulated AcoAA.

Concentración de la cirugía de aneurisma de aorta abdominal roto en centros especializados calificados / Concentrating ruptured abdominal aortic aneurysm surgery in specialized centers

Ruptured abdominal aortic aneurysm (RAAA) is an arterial emergency with an overall mortality of 80%-90% secondary to massive hemorrhage. If a patient with RAAA presents in a primary hospital without resolution capacity, survival will depend on early transfer to a center with adequately trained specialists. This article reviews the evidence supporting the centralization of AAAR treatment in qualified centers, specifying the criteria used for the selection of referral centers and the role of a coordinating unit. Our current referral system, which is based primarily on costs, is also described. Patients with AAAR who consult in non-resolving centers should be rapidly transferred to a qualified referral center, following a transfer protocol, and guided by a coordinating unit acting according to technical and established criteria based on results, quality, and costs. Qualified referral centers should have an accredited vascular surgeon and a high institutional aortic surgery volume, adequate infrastructure, endovascular resolution capacity, support services (intensive care, hemodialysis, etc.) and specialized personnel permanently available.

Surgical clipping of ruptured posterior communicating artery aneurysms originating from fetal-type posterior cerebral artery via lateral supraorbital approach / 国际脑血管病杂志

Objective:To investigate the therapeutic effect of surgical clipping ruptured posterior communicating artery aneurysms (PCoAA) originating from fetal-type posterior cerebral artery (FPCA) via lateral supraorbital approach and the influencing factors of the outcomes.Methods:Patients with ruptured PCoAA originating from FPCA underwent surgical clipping via lateral supraorbital approach in the Cerebrovascular Center of Foshan Hospital of Traditional Chinese Medicine from January 2017 to May 2020 were retrospectively enrolled. The Glasgow Outcome Scale was used to evaluate the outcomes of patients at 6 months after operation. 4-5 points were defined as good outcome, and 1-3 points were defined as poor outcome. Multivariable logistic regression analysis was used to determine the risk factors for poor outcomes. Results:A total of 119 patients were enrolled, including 98 females (82.35%), aged 61.59±11.52 years old (range 32-78 years). Thirty patients (25.21%) had poor outcomes. Multivariable logistic regression analysis showed that age (odds ratio [ OR] 2.935, 95% confidence interval [ CI] 2.117-5.391; P=0.012), hypertension ( OR 2.016, 95% CI 1.568-4.335; P=0.023), Hunt-Hess grade ( OR 2.408, 95% CI 1.326-5.068; P<0.001), modified Fisher grade ( OR 3.034, 95% CI 2.201-5.517; P<0.001), aneurysm size ( OR 1.793, 95% CI 1.427-2.622; P=0.009), preoperative intracranial hematoma volume ( OR 1.246, 95% CI 1.055-2.153; P=0.011) and surgical timing ( OR 2.152, 95% CI 1.316-3.240; P=0.006) were the independent risk factors for poor outcomes of the patients. Conclusions:Surgical clipping via lateral supraorbital approach can effectively treat the ruptured PcoAA with FPCA. Patients with age >65 years, with a history of hypertension, high Hunt-Hess grade, high modified Fisher grade, aneurysms >7.65 mm, preoperative intracranial hematoma volume >19.02 ml, and late surgery need to strengthen postoperative management to improve outcomes.

Abdominal aortic aneurysms ruptured to the vena cava: a case series and literature review / Aneurismas de aorta abdominal rotos para a veia cava: uma série de casos e revisão de literatura

Abstract Ruptured abdominal aortic aneurysms (RAAA) evolving aortocaval fistula (AF) can have catastrophic hemodynamic effects. Surgical repair is imperative, but the optimal technical approach is still under debate. Our objective is to present 3 cases treated with endovascular repair (EVAR) at a University Hospital. Case #1, a 71-year-old man presenting a 7.1cm RAAA with AF, repaired with a monoiliac stent graft and femoral-femoral bypass; Case #2, a 76-year-old man presenting a 9.9cm RAAA with AF, repaired with a bifurcated stent graft; Case #3, a 67-year-old man with previous history of EVAR, presenting a type 3 endoleak with late rupture related to AF, repaired with a tubular stent graft. All cases unfolded with delayed recovery and significant complication rates, although AF symptoms had resolved by hospital discharge. EVAR techniques for AF may require secondary interventions but are feasible, despite the lack of consensus, considering the rarity of this RAAA presentation.

Resumo Aneurismas de aorta abdominal rotos (AAAR) com evolução para fístula aorto-cava (FAC) podem apresentar consequências hemodinâmicas catastróficas. A correção cirúrgica é mandatória, embora não haja consenso sobre a técnica operatória. Apresentamos uma série de três casos operados em hospital universitário pela técnica endovascular. No primeiro caso, um homem de 71 anos apresentou AAAR de 7,1 cm com FAC, submetido a correção por endoprótese monoilíaca e enxerto femoral cruzado. No segundo, um homem de 76 anos apresentou AAAR de 9,9 cm com FAC submetido a colocação de endoprótese bifurcada. O terceiro caso era de um homem de 67 anos com histórico de EVAR e endoleak tipo 3, com ruptura tardia para veia cava, tratado com extensão aórtica. Todos apresentaram evolução pós-operatória prolongada com significativas complicações, entretanto com boa resolução dos sintomas à alta hospitalar. A EVAR é uma técnica promissora para o tratamento de FAC, embora com taxa de reintervenção significativa.

Application of ultrasound-guided stellate ganglion block in patients with aneurysmal intracerebral hemorrhage / 中国医师进修杂志

Objective To explore the application value of ultrasound-guided stellate ganglion block in patients with aneurysmal cerebral hemorrhage.Methods Eighty patients with subarachnoid hemorrhage caused by aneurysm from November 2017 to March 2019 in Hangzhou Hospital of Zhejiang Medical Health Group were selected.The patients were divided into observation group and control group by random digits table method with 40 cases in each group.All patients were treated with craniotomy hematoma removal.At the conclusion of the surgical procedure,the control group was treated with nimodipine,while the observation group was treated with ultrasound-guided right stellate ganglion block on the basis of nimodipine.The blood flow velocity of middle cerebral artery before operation and 6,24 h after operation by transcranial Doppler sonography were detected to reflect cerebral vasospasm status;the blood samples from the radial artery and internal jugular bulb 24 h after operation were used to detect and count cerebral oxygen metabolism indexes,including the blood oxygen saturation of internal jugular bulb,arteriovenous oxygen content difference and cerebral oxygen uptake rate;the IgG,IgA and IgM 24 h after operation were detected.The patients were followed up at 1 week after operation,and the complication was observed.Results There was no statistical difference in the blood flow velocity of middle cerebral artery before operation between 2 groups (P＞0.05);the blood flow velocity of middle cerebral artery 6 and 24 h after operation in observation group was significantly lower than that in control group:(100.8± 8.2) cm/s vs.(123.5 ± 9.9) cm/s and (89.7 ± 5.3) cm/s vs.(118.9 ± 7.1) cm/s,and there was statistical difference (P＜0.01).The blood oxygen saturation of internal jugular bulb,cerebral oxygen uptake rate,IgG,IgA and IgM 24 h after operation in observation group were significantly higher than those in control group:0.704 ± 0.035 vs.0.598 ± 0.058,(57.5 ± 6.5)％ vs.(49.7 ± 3.6)％,(12.5 ± 0.3) mg/L vs.(5.0 ± 0.1) mg/L,(5.5 ± 0.3) mg/L vs.(2.1 ± 0.1) mg/L and (4.3 ± 0.3) mg/L vs.(1.9 ± 0.2) rg/L,the arteriovenous oxygen content difference and incidence of complication were significantly lower than those in control group:(40.8 ± 3.2) ml/L vs.(58.3 ± 8.6) ml/L and 5.0％ (2/40) vs.25.0％ (10/40),and there were statistical differences (P＜0.01 or ＜0.05).Conclusions For patients with aneurysmal intracerebral hemorrhage,ultrasound-guided stellate ganglion block therapy can effectively improve cerebral blood flow,ensure cerebral oxygen supply,improve humoral immunity,reduce the incidence of postoperative complication,and achieve the purpose of improving clinical therapeutic effect.

Pseudoaneurisma micótico por embolismo séptico en paciente pediátrico con leucemia linfoblástica aguda / Mycotic aneurism for septic embolism in a pediatric patient with acute linfoblastic leukemia

Resumen Los aneurismas pediátricos son raros y pueden se causados por infección al dañar la pared arterial formando una saculación ciega contigua a su lumen denominada pseudoaneurisma micótico. La mayoría de los casos reportados son de pacientes ancianos con comorbilidades y los agentes causantes más frecuentes son Staphylococcus spp, Salmonella spp, Streptococcus spp y raramente hongos. Se presenta el caso de un niño de 3 años con: diagnóstico reciente de leucemia linfoblástica aguda de precursores B en remisión; alto riesgo de recaída por tratamiento incompleto y antecedente de bacteremia por Staphylococcus epidermidis y fungemia por Cándida tropicalis; vegetaciones cardiacas que hacen embolismo a hígado, bazo, pulmón y cerebro, y pseudoaneurisma micótico parcialmente trombosado de la arteria ilíaca común y externa. El diagnóstico temprano de esta entidad es de vital importancia por el riesgo de ruptura y el manejo quirúrgico dependerá de la localización, el tamaño y las complicaciones asociadas.

Abstract Pediatric aneurysms are rare and can be caused for damaging of the arterial wall secondary to an infection, forming a blind sacculation contiguous to its lumen called mycotic pseudoaneurysm. The majority of reported cases are from elderly patients with comorbidities. The most frequent involucre microorganisms are Staphylococcus spp, Salmonella spp, Streptococcus spp and rarely fungi. We present the case of a 3-year-old boy, with a recent diagnosis of acute lymphoblastic leukemia of B precursors in remission, with a high risk of relapse due to incomplete treatment and a history of bacteremia due to Staphylococcus epidermidis and fungemia due to Candida tropicalis; with cardiac vegetations that produce liver, spleen, lung and brain embolism, in whom a partially thrombosed mycotic pseudoaneurysm of the common and external iliac artery is found. The early diagnosis of this entity is of vital importance because of the risk of rupture. Surgical management will depend on the location, size and associated complications.

Should Cerebral Angiography Be Avoided within Three Hours after Subarachnoid Hemorrhage?

OBJECTIVE: While the risk of aneurysmal rebleeding induced by catheter cerebral angiography is a serious concern and can delay angiography for a few hours after a subarachnoid hemorrhage (SAH), current angiographic technology and techniques have been much improved. Therefore, this study investigated the risk of aneurysmal rebleeding when using a recent angiographic technique immediately after SAH. METHODS: Patients with acute SAH underwent immediate catheter angiography on admission. A four-vessel examination was conducted using a biplane digital subtraction angiography (DSA) system that applied a low injection rate and small volume of a diluted contrast, along with appropriate control of hypertension. Intra-angiographic aneurysmal rebleeding was diagnosed in cases of extravasation of the contrast medium during angiography or increased intracranial bleeding evident in flat-panel detector computed tomography scans. RESULTS: In-hospital recurrent hemorrhages before definitive treatment to obliterate the ruptured aneurysm occurred in 11 of 266 patients (4.1%). Following a univariate analysis, a multivariate analysis using a logistic regression analysis revealed that modified Fisher grade 4 was a statistically significant risk factor for an in-hospital recurrent hemorrhage (p =0.032). Cerebral angiography after SAH was performed on 88 patients ≤3 hours, 74 patients between 3–6 hours, and 104 patients >6 hours. None of the time intervals showed any cases of intra-angiographic rebleeding. Moreover, even though the DSA ≤3 hours group included more patients with a poor clinical grade and modified Fisher grade 4, no case of aneurysmal rebleeding occurred during erebral angiography. CONCLUSION: Despite the high risk of aneurysmal rebleeding within a few hours after SAH, emergency cerebral angiography after SAH can be acceptable without increasing the risk of intra-angiographic rebleeding when using current angiographic techniques and equipment.

Clinical effect of staged stent-assisted embolization after initial coiling of acute ruptured wide-neck saccular intracranial aneurysms / 中国脑血管病杂志

Objective: To evaluate the safety and efficacy of coiling in the acute phase followed by staged stenting for ruptured wide-neck saccular intracranial aneurysms. Methods: From November 2006 to December 2017, We retrospectively reviewed 58 consecutive patients with acute ruptured wide-neck saccular intracranial aneurysms(58 ruptured wide-neck saccular intracranial aneurysms) who were treated with staged stent-assisted embolization after initial coiling in the Department of Neurosurgery of NO. 971 Hospital of PLA Navy and the Department of Neurosurgery of First Hospital Affiliated to Naval Medical University. Simple coiling embolization was performed in the acute phase, and stent implantation was performed in the second stage. The immediate postoperative and follow-up angiographic results were assessed using the Raymond scale, and the outcome of clinical follow-up was assessed using the modified Rankin Scale(MRS). Results: All 58 patients(58 ruptured wide-neck saccular intracranial aneurysms) were successfully treated with staged stent-assisted embolization. The median interval of staged stenting treatment was 4. 4(4. 1, 4. 9) weeks. No aneurysm rebleeding occurred prior to the staged stenting treatment. During the treatment of staged stenting, coils were used as many as possible for embolization under the mechanical protection of stents in order to achieve complete occlusion. Immediately after stenting, angiography showed 30 aneurysms (51. 7%) with complete occlusion, 22 aneurysms (37. 9%) with neck remnant and 6aneurysms(10. 3%) with residual sac. One patient suffered in-stent thrombosis two hours after stent implantation, which was relieved with the use of tirofiban. When discharging hospital, showing that a total of 46 patients (79.3%) had MRSO-2, 8 patients(13.8%) had MRS 3 and 4 patients(6.9%) had MRS 4. Imaging follow-up ranged 6-35 months (median 16 months), showing 47 aneurysms (81. 0%) with complete occlusion, 7 aneurysms(12. 1%) with residual neck and 4 aneurysms(6. 9%) with residual sac. There was no recurrence, and the parent arteries were patent in all cases. Clinical follow-up ranged 6-36 months(median 18 months), showing that a total of 8 patients(13. 8%) had MRS 0-2 and 50 patients (86. 2%) had MRS 3. There was no new neurological dysfunction or death. Conclusion: Treatment of ruptured wide-neck saccular aneurysms with coiling in the acute phase followed by staged stenting is safe and effective.

Clinical analysis of 60 cases of recurrent hemorrhage after ruptured intracranial aneurysm / 中国基层医药

Objective@#To investigate the clinical features of rebleeding after ruptured intracranial aneurysms.@*Methods@#A retrospective analysis was made on the diagnosis and treatment of 60 patients with ruptured intracranial aneurysms from February 2017 to February 2018 in Taizhou Hospital.According to the patients' rebleeding, the patients were divided into the control group and the observation group, with 30 cases in each group.The patients' medical records were collected.The causes, time periods, clinical manifestations and time intervals and times of rebleeding were analyzed.At the same time, the position and size of the aneurysm, the Hunt-Hess score and the combination of hypertension in the two groups were compared.@*Results@#The causes of rebleeding in the observation group were intraoperative rupture, premature movement and ambulation, defecation, abnormal mood and no obvious inducement.Preoperative rebleeding occurred in 24 cases: 19 cases before admission, 4 cases after admission, 1 case before and after admission, and 6 cases of bleeding during operation.The clinical manifestations of rebleeding in the observation group were apnea, pathological reflex, one side/bilateral pupil, light hemiplegia, meningeal irritation, and systemic convulsion and ankylosis.In the observation group, the proportions of patients with bleeding below 8d, 8-14d, 15-21d, 22-30d and more than 30d were 46.67%, 23.33%, 13.33%, 10.00% and 6.67%.There were no statistically significant differences in the position and size of the aneurysm between the two groups (all P>0.05). The Hunt-Hess scores of grade Ⅰ, Ⅱ, Ⅲ, Ⅳ in the observation group were 33.33%, 40.00%, 16.67% and 10.00%, respectively, and the Hunt-Hess scores of grade Ⅰ, Ⅱ, Ⅲ, Ⅳ, Ⅴ in the control group was 10.00%, 36.67%, 30.00%, 20.00% and 3.33%, respectively, the difference was statistically significant (u=2.507, P=0.012). There was no statistically significant difference in the incidence of hypertension between the two groups (χ2=0.161, P>0.05).@*Conclusion@#The recurrence of intracranial aneurysms is not related to the location and size of aneurysms, and the association between hypertension and disease.It is closely related to the Hunt-Hess score.

Correlation between blood glucose and aneurysm rupture / 中国医师进修杂志

Objective@#To investigate the correlation between blood glucose and aneurysm rupture, and analyze the correlation factors of aneurysm rupture.@*Methods@#The clinical data of 128 patients with intracranial aneurysms in the First Affiliated Hospital of Kunming Medical University from January 2017 to August 2018 were retrospectively analyzed. Among them, intracranial aneurysm rupture was in 85 cases (rupture group), and unruptured was in 43 cases (unruptured group). The patient′s clinical features and aneurysm morphological features were recorded.@*Results@#The blood glucose, daughter sac rate and regularity of morphology rate in ruptured group were significantly higher than those in unruptured group: (6.74 ± 2.61) mmol/L vs. (5.77 ± 2.11) mmol/L, 60.00% (51/85) vs. 11.63% (5/43), and 68.24% (58/85) vs. 30.23% (13/43), the aneurysm width was significantly smaller than that in unruptured group: (4.53 ± 2.25) mm vs. (5.67 ± 2.68) mm, and there were statistical differences (P<0.05 or <0.01). There were no statistical difference in gender, age, blood pressure, diabetes, hypertension, smoking history, glycosylated hemoglobin, blood lipids, aneurysm length, aneurysm neck, aneurysm length ratio to neck between 2 groups (P>0.05). Univariate Logistic regression analysis result showed that blood glucose, aneurysm width, daughter ascus and irregular shape were the risk factors of rupture of aneurysm (P<0.05 or <0.01). Multivariate Logistic regression analysis result showed that blood glucose, aneurysm width, daughter sac and irregular shape were the independent risk factors of rupture of aneurysm (OR = 1.364, 0.709, 9.441 and 3.935; 95% CI 1.073 to 1.734, 0.565 to 0.889, 2.879 to 30.963 and 1.330 to 11.646; P = 0.011, 0.003, 0.000 and 0.013). The patients were grouped again according to the aneurysm width, and univariate Logistic regression analysis result showed that aneurysm width ≤ 3 mm was the risk factors of rupture of aneurysm (OR = 0.294, 95% CI 0.094 to 0.916, P = 0.035).@*Conclusions@#Irregular shape and daughter sac of aneurysm are the independent risk factors of aneurysm rupture, but aneurysm rupture has nothing to do with recent blood sugar levels.

Clinical analysis of 60 cases of recurrent hemorrhage after ruptured intracranial aneurysm / 中国基层医药

Objective To investigate the clinical features of rebleeding after ruptured intracranial aneurysms.Methods A retrospective analysis was made on the diagnosis and treatment of 60 patients with ruptured intracranial aneurysms from February 2017 to February 2018 in Taizhou Hospital.According to the patients＇rebleeding, the patients were divided into the control group and the observation group ,with 30 cases in each group.The patients＇medical records were collected.The causes, time periods, clinical manifestations and time intervals and times of rebleeding were analyzed.At the same time,the position and size of the aneurysm ,the Hunt -Hess score and the combination of hypertension in the two groups were compared.Results The causes of rebleeding in the observation group were intraoperative rupture , premature movement and ambulation ,defecation,abnormal mood and no obvious inducement.Preoperative rebleeding occurred in 24 cases:19 cases before admission,4 cases after admission,1 case before and after admission,and 6 cases of bleeding during operation.The clinical manifestations of rebleeding in the observation group were apnea ,pathological reflex,one side／bilateral pupil,light hemiplegia,meningeal irritation,and systemic convulsion and ankylosis.In the observation group,the proportions of patients with bleeding below 8d,8-14d,15-21d,22-30d and more than 30d were 46.67%,23.33%,13.33%,10.00% and 6.67%.There were no statistically significant differences in the position and size of the aneurysm between the two groups ( all P＞0.05). The Hunt-Hess scores of grade Ⅰ,Ⅱ,Ⅲ,Ⅳ in the observation group were 33.33%,40.00%,16.67% and 10.00%,respectively,and the Hunt -Hess scores of grade Ⅰ,Ⅱ,Ⅲ,Ⅳ,Ⅴ in the control group was 10.00%, 36.67%,30.00%,20.00% and 3.33%,respectively,the difference was statistically significant ( u ＝2.507,P＝0.012).There was no statistically significant difference in the incidence of hypertension between the two groups (χ2 ＝0.161,P＞0.05).Conclusion The recurrence of intracranial aneurysms is not related to the location and size of aneurysms,and the association between hypertension and disease.It is closely related to the Hunt -Hess score.

External Ventricular Drainage before Endovascular Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage in Acute Period: Its Relation to Hemorrhagic Complications / 신경중재치료의학

PURPOSE: The purpose of this study was to report the authors’ experience with external ventricular drainage (EVD) before endovascular treatment (EVT) in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) and to investigate its relation to hemorrhagic complications. MATERIALS AND METHODS: Between March 2010 and December 2017, a total of 122 patients were recruited who had an aSAH, underwent EVT to secure the ruptured aneurysm, and had EVD performed within 72 hours of rupture. The pre-embo EVD group (n=67) comprised patients who underwent EVD before EVT, and the post-embo EVD group (n=55) comprised those who underwent EVD after EVT. RESULTS: Overall, EVD-related hemorrhage occurred in 18 patients (14.8%): six (8.9%) in the pre-embo EVD group and 12 (21.8%) in the post-embo EVD group (P=0.065). No rebleeding occurred between EVD and EVT in the pre-embo EVD group. Clinical outcomes at discharge did not differ significantly between groups (P=0.384). At discharge, the final modified Rankin Scale score in patients who experienced pre-embo rebleeding was better in the pre-embo EVD group than in the post-embo EVD group (P=0.041). Current use of an antiplatelet agent or anticoagulant on admission (odds ratio [OR], 2.928; 95% confidence interval [CI], 1.234–7.439; P=0.042) and stent use (OR, 2.430; 95% CI, 1.524–7.613; P=0.047) remained independent risk factors for EVD-related hemorrhagic complications. CONCLUSION: EVD before EVT in patients with aSAH in acute period did not increase the rate of rebleeding as well as EVD-related hemorrhagic complications. Thus, performing EVD before EVT may be beneficial by normalizing increased intracranial pressure. Especially in patients with rebleeding before the ruptured aneurysm is secured, pre-embo EVD may improve clinical outcomes at discharge.

Treatment of elderly patients with aneurysmal subarachnoid hemorrhage: comparison between surgical clipping and endovascular coil embolization / 国际脑血管病杂志

Objective To compare the treatment effect of surgical clipping and endovascular coil embolization for aneurysmal subarachnoid hemorrhage (aSAH) in the elderly.Methods Elderly patients with aSAH (aged ＞65 years) treated in Shanghai Pudong Hospital from January 2009 to December 2017 were enrolled retrospectively.They were divided into craniotomy clipping group and endovascular intervention group according to the treatment strategy.The Glasgow Outcome Scale w as used for short-term outcome assessment at discharge,4-5 were defined as good outcome,and 1-3 were defined as poor outcome.Longterm follow-up w as performed to assess clinical outcomes using the modified Rankin Scale,0-2 w as defined as good outcome and 3-6 w ere defined as poor outcome.The clinical and imaging information,perioperative complications,short-term and long-term clinical outcomes,and long-term imaging outcomes w ere compared between the two groups.Multivariate logistic regression analysis was used to assess the independent influencing factors of clinical outcomes.Results A total of 68 elderly patients with aSAH were enrolled.Of these,47 (69.1％) received endovascular coil embolization and 21 (30.9％) underwent microsurgical clipping.There were no significant differences between the two groups in the incidence of perioperative complications,short-term and long-term adverse outcomes,and imaging recurrence rate.Multivariate logistic analysis showed that smoking (odds ratio [OR] 36.319,95％ confidence interval [CI] 3.530-373.640;P =0.003),modified Fisher grade (OR 20.406,95％ CI 2.022-205.964;P =0.011) and World Federation of Neurological Societies (WFNS) grade (OR 4.686,95％ CI 1.012-21.692;P=0.048) were the independent risk factors for short-term poor outcomes in elderly patients with aSAH.Conclusion Both endovascular intervention and microsurgical clipping are safe and effective treatments for elderly patients with aSAH.

Stent-assisted coil embolization for ruptured anterior circulation intracranial aneurysms:comparison with non-stent-assisted coil embolization / 国际脑血管病杂志

Objective To compare the safety and efficacy of stent-assisted and non-stent-assisted coil embolization for the treatment of ruptured anterior circulation aneurysms. Methods From January 2014 to September 2018, patients with ruptured anterior circulation aneurysms treated with interventional embolization in Dezhou People ' s Hospital were enrolled retrospectively. The incidence of perioperative complications, mortality, and clinical outcome at 30 d after coil embolization were compared between the stent-assisted embolization group and the non-stent-assisted embolization group. Multivariate logistic regression analysis was used to determine the independent risk factors for poor outcomes. Results A total of 115 aneurysms were included in 115 patients. There were 47 patients in the stent-assisted embolization group (16 males, aged 56. 81 ±10. 16 years) and 68 in the non-stent-assisted embolization group (27 males, aged 52. 38 ± 9. 60 years ). There were no significant differences in the demographic and baseline data between the stent-assisted embolization group and the non-stent-assisted embolization group. There were no significant differences in the incidence of bleeding complications, ischemic complications, and symptomatic cerebral vasospasm as well. However, the overall complication rate (34. 04％ vs. 17. 65％; P = 0. 044), poor outcome rate (27. 66％ vs. 10. 29％; P = 0. 016 ), and mortality (14. 89％ vs. 2. 94％; P = 0. 046 ) in stent-assisted embolization group were significantly higher than those in the non-stent assisted embolization group. Multivariate logistic regression analysis indicated that hypertension (odds ratio [OR] 6. 000, 95％ confidence interval [CI] 1. 361-27. 363; P = 0. 021), diabetes (OR 6. 000, 95％ CI 1. 548-23. 255; P = 0. 010), stent-assist technique (OR 12. 201, 95％ CI 2. 588-102. 002; P = 0. 002), perioperative bleeding complications (OR 40. 286, 95％ CI 4. 508-360. 032; P = 0. 001), and ischemic complications (OR 46. 000, 95％ CI 10. 716-197. 460; P < 0. 001) were the independent risk factors for poor outcomes. Conclusion Stent-assisted coil embolization for ruptured anterior circulation aneurysms has a high incidence of complications and poor clinical outcomes, and should be avoided as much as possible.

Should Cerebral Angiography Be Avoided within Three Hours after Subarachnoid Hemorrhage?

OBJECTIVE: While the risk of aneurysmal rebleeding induced by catheter cerebral angiography is a serious concern and can delay angiography for a few hours after a subarachnoid hemorrhage (SAH), current angiographic technology and techniques have been much improved. Therefore, this study investigated the risk of aneurysmal rebleeding when using a recent angiographic technique immediately after SAH.METHODS: Patients with acute SAH underwent immediate catheter angiography on admission. A four-vessel examination was conducted using a biplane digital subtraction angiography (DSA) system that applied a low injection rate and small volume of a diluted contrast, along with appropriate control of hypertension. Intra-angiographic aneurysmal rebleeding was diagnosed in cases of extravasation of the contrast medium during angiography or increased intracranial bleeding evident in flat-panel detector computed tomography scans.RESULTS: In-hospital recurrent hemorrhages before definitive treatment to obliterate the ruptured aneurysm occurred in 11 of 266 patients (4.1%). Following a univariate analysis, a multivariate analysis using a logistic regression analysis revealed that modified Fisher grade 4 was a statistically significant risk factor for an in-hospital recurrent hemorrhage (p =0.032). Cerebral angiography after SAH was performed on 88 patients ≤3 hours, 74 patients between 3–6 hours, and 104 patients >6 hours. None of the time intervals showed any cases of intra-angiographic rebleeding. Moreover, even though the DSA ≤3 hours group included more patients with a poor clinical grade and modified Fisher grade 4, no case of aneurysmal rebleeding occurred during erebral angiography.CONCLUSION: Despite the high risk of aneurysmal rebleeding within a few hours after SAH, emergency cerebral angiography after SAH can be acceptable without increasing the risk of intra-angiographic rebleeding when using current angiographic techniques and equipment.

Treatment of elderly patients with aneurysmal subarachnoid hemorrhage: comparison between surgical clipping and endovascular coil embolization / 国际脑血管病杂志

Objective@#To compare the treatment effect of surgical clipping and endovascular coil embolization for aneurysmal subarachnoid hemorrhage (aSAH) in the elderly.@*Methods@#Elderly patients with aSAH (aged >65 years) treated in Shanghai Pudong Hospital from January 2009 to December 2017 were enrolled retrospectively. They were divided into craniotomy clipping group and endovascular intervention group according to the treatment strategy. The Glasgow Outcome Scale was used for short-term outcome assessment at discharge, 4-5 were defined as good outcome, and 1-3 were defined as poor outcome. Long-term follow-up was performed to assess clinical outcomes using the modified Rankin Scale, 0-2 was defined as good outcome and 3-6 were defined as poor outcome. The clinical and imaging information, perioperative complications, short-term and long-term clinical outcomes, and long-term imaging outcomes were compared between the two groups. Multivariate logistic regression analysis was used to assess the independent influencing factors of clinical outcomes.@*Results@#A total of 68 elderly patients with aSAH were enrolled. Of these, 47 (69.1%) received endovascular coil embolization and 21 (30.9%) underwent microsurgical clipping. There were no significant differences between the two groups in the incidence of perioperative complications, short-term and long-term adverse outcomes, and imaging recurrence rate. Multivariate logistic analysis showed that smoking (odds ratio [OR] 36.319, 95% confidence interval [CI] 3.530-373.640; P=0.003), modified Fisher grade (OR 20.406, 95% CI 2.022-205.964; P=0.011) and World Federation of Neurological Societies (WFNS) grade (OR 4.686, 95% CI 1.012-21.692; P=0.048) were the independent risk factors for short-term poor outcomes in elderly patients with aSAH.@*Conclusion@#Both endovascular intervention and microsurgical clipping are safe and effective treatments for elderly patients with aSAH.

Clinical efficacy of LVIS stent combined with coil embolization of ruptured wide-necked intracranial aneurysms during the acute phase / 中国脑血管病杂志

Objective To investigate the safety and efficacy of LVIS stent combined with coil embolization of ruptured wide-necked intracranial aneurysms during the acute phase.Methods From May 2014 to August 2017,the clinical and imaging data of 56 patients with ruptured wide-necked intracranial aneurysm treated with LVIS stents for acute phase assisted embolization at the Department of Neurosurgery,the Affiliated Hospital of Southwest Medical University were analyzed retrospectively.All patients were treated with LVIS stent combined with coil embolization.Immediate postoperative angiography,six months after procedure,and follow-up imaging were evaluated by Raymond grade (RS grade).The clinical follow-up results were evaluated by the modified Rankin Scale (mRS) score.Results LVIS stent combined with coil embolization was performed in 56 patients with 60 aneurysms in this group.The success rate of stent release was 100％.Immediate angiography after procedure showed that the complete embolization rate of aneurysms was 80.0％ (48/60),the near complete embolization rate was 13.3 ％ (8/60),and the incomplete embolization rate was 6.7％ (4/60).Postoperative follow-up angiography at 6 monthrevealed that the complete embolization rate of aneurysms was 87.8％ (36/41),nearly complete embolization rate was 7.3％ (3/41),incomplete embolization rate was 4.9％ (2/41).Postoperative follow-up angiography at 12 months revealed that the complete embolization rate of aneurysms was 83.0％ (39/47),and near complete embolization rate was 12.8％ (6/47),and incomplete embolization rate was 4.3％ (2/47).Of the 56 patients,49 were followed up clinically and 7 were lost to follow up.The average follow-up time was 13 ± 4 months.The clinical follow-up showed that the good prognosis (mRS score 0-2) rate was 87.8％ (43/49).Intraoperative complications occurred in 7 cases,5 were intraoperative parent artery thrombosis and 2 were intraoperative aneurysm rupture.Conclusions LVIS stent combined with coil embolization of ruptured wide-necked intracranial aneurysms during the acute phase has good efficacy and safety.Its long-term efficacy remains to be confirmed by long-term follow-up.

Endovascular reconstruction for ruptured and unruptured vertebral artery fusiform aneurysms / 中国脑血管病杂志

Objective To investigate the safety and efficacy of endovascular reconstruction for ruptured and unruptured vertebral artery fusiform aneurysms (VAFAs).Methods The clinical,imaging and follow-up data of 26 consecutive patients with VAFA treated with endovascular reconstruction at the Department of Neurosurgery,Beijing Hospital between October 2009 and September 2017 were analyzed retrospectively.Results (1) Twenty-six patients had 26 VAFAs.Their age ranged from 38 to 69 years old.Nine patients had ruptured aneurysms and 17 had unruptured aneurysms.The diameter of the aneurysms ranged from 5 to 12 mm.The success rate of reconstruction technology was 100％.(2)In 9 patients of the rupture group,8 were embolized by stent-assisted coils,1 was treated with stent-assisted coil embolization alone.Five patients were treated with multiple-stent reconstruction and 4 were treated with stent reconstruction alone.Of the 17 patients in the unrupture group,13 were treated with stent-assisted embolization and 4 were treated with stent implantation alone;7 were treated with multiple-stent reconstruction,and 10 were treated with stent reconstruction alone.No perioperative complications occurred.(3) The patients were followed up for 8.0-97.5 months with a median time of 39.5 months.No new cerebral infarction or cerebral hemorrhage occurred.The patients with good prognosis (the modified Rankin scale scale 0-2) was 100％.Twenty-two patients were followed up for 3.5 to 34.0 months with a median time of 10.3 months.Fourteen patients (63.6％) were cured,4 (18.2％) were stable or improved,and 4 (18.2％) had recurrence;Five of 8 patients were cured in the rupture group;9 of 14 were cured in the unrupture group.There were 2 cases of relapse in each of the two groups.Conclusions Endovascular reconstruction for ruptured and unruptured VAFAs is clinically feasible and the safety is higher.The efficacy of mid-term and long-term follow-up is better.The recurrence rate of ruptured VAFAs has an increasing trend,and close follow-up is required after procedure.